The present invention relates generally to physician credentialing and verification systems and, in particular, to systems capable of automatically generating a plurality of different insurance provider application forms in different formats based on a common set of physician credentialing information.
Physician credentialing is the process that physicians, and other related health care professionals who must submit credentialing data, undergo in order to become or remain affiliated with a particular health care provider organization (such as, for example, a managed health care group, a hospital or an insurance organization). Typically such physicians must complete an extensive application form and submit the completed form to the health care provider organization for review and acceptance. This process of completing and submitting application forms occurs both when the physician originally becomes affiliated with the health care provider organization and when the organization requires its affiliated physicians to re-credential themselves, i.e., re-submit their applications with up-to-date information. Currently, although the information required by each health care provider organization is generally similar in nature to that required by other, each provider organization normally uses an application form customized to its own needs and requirements, in its own distinct format, and designed to elicit information that is important to that particular provider organization, which, as discussed below, often places an unnecessary and unwanted ever increasing burden on the physician in today""s health care environment, particularly if the physician is affiliated with several health care organizations.
Credentials verification is a related process whereby health care provider organizations verify the accuracy of the information contained in application forms submitted by physicians seeking appointment or re-appointment with the provider organization. Usually, to complete the credentials verification process, it is necessary to access several different sources to verify the information. Such sources may include, for example, state licensing boards, medical schools, the American Board of Medical Specialties, and the National Practitioner Data Bank. As required by governmental rules and regulations, each health care provider organization must individually and independently perform primary source verification and is prohibited from sharing the gathered information with other similarly situated provider organizations.
Currently, there are over 600,000 physicians in the United States, substantially all of whom are affiliated with a number of health care provider organizations. As the health care industry continues its current state of rapid expansion, new provider organizations are continuously entering the marketplace. It is not uncommon for physicians to service patients associated with several managed care organizations, be affiliated with more than one hospital, and interact with several insurance companies that insure their patients. Typically, physicians must be re-credentialed ever year or two by every organization with which they are affiliated. Thus, statistics show that, on average, each physician must complete and submit in the neighborhood of six credentialing application forms annually. While there have been some attempts to develop a standardized credentialing application format, these efforts have been largely unsuccessful. Because of the wide variety and number of formats, the process to complete all of the various forms is necessarily time consuming, inefficient, and labor intensive, particularly since these forms are generally manually completed due to the distinctions in format peculiar to each organization.
Thus, there is an ever increasing need to assist physicians and related health care professionals, as well as the organizations that manage such professionals, with the completion of these credentialing application forms in a system which would allow physicians to automatically selectively generate a credentialing application tailored to a particular provider organization, from a plurality of different selectable choices in form and format, based upon a common set of pre-stored credentialing information about the physician. The preferred system would thus reduce the time and cost associated with the completion of these application forms and would help to minimize the possibility of introducing errors into in these forms.
Thus, the disadvantages of prior art credentialing systems are overcome by the present invention, which is an automated system and method for selectively generating credentialing applications tailored to particular provider organizations.
The presently preferred method of the present invention comprises a method for selectively generating a plurality of different provider application forms based on a common set of physician credentialing information, which method comprises the steps of storing a plurality of physician credentialing profiles containing physician credentialing information in a database, storing a plurality of different selectable provider application formats in a database requiring data which is a subset of the information stored in the physician credentialing profiles, automatically selectively inputting the subset of physician credentialing information required by a particular selectable provider application format into a provider application form, and generating the selected particular provider application form containing information inputted from the subset of stored physician credentialing information.
Preferably, the physician credentialing profiles are stored based on information provided by the physician on a universal application form that contains credentialing information regarding a particular physician. This universal application form may be completed in an number of ways including on a paper form, electronically and stored to a computer disk, or through an on-line service.
The presently preferred system of the present invention, which is intended to relieve practitioners, health care providers and organizations of the administrative burdens of completing multiple different forms associated with practitioner credentialing, comprises means for storing the plurality of physician credentialing profiles in the data base, means for storing the plurality of different provider application formats in the data base, means for automatically inputting the subset of physician credentialing information required by a particular provider application format into the provider application format, and means for generating the completed selected particular provider application form.